Essential Research Findings in Counselling and Psychotherapy

The Facts are Friendly

Mick Cooper

• Publisher: SAGE Publications Ltd
• Year: 2008
• ISBN:
  9781446242650
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

Are some therapies more effective than others? How important is the relationship? Which clients do best in therapy?

Essential Research Findings in Counselling and Psychotherapy answers these questions and many more, providing trainees, practitioners and researchers with a comprehensive introduction to the latest findings in the field. The book sets out in a jargon-free way the evidence for the effectiveness of therapy and the factors associated with positive therapeutic outcomes. It gives suggestions for further reading, definitions of key terms and questions for discussion, making this an ideal text for use in training.

The book is also designed for practitioners who increasingly need to justify their therapeutic work on empirical grounds. Essential Research Findings in Counselling and Psychotherapy gives them the knowledge and confidence to do just that. More than that, it makes research findings accessible and provides information on how to practice counselling and psychotherapy in an effective way.

1

Introduction: the Challenge of Research

This chapter discusses:

• The value of applying research findings to practice.
• The limitations of applying research findings to practice.
• The aims of the book.
• The personal, theoretical and methodological perspective from which the book is written.
• What is in the book … and what is not.
• How the book is structured.

The Value of Research

Research findings can be like many things. They can be like dusty old library books hidden away, decomposing and seemingly irrelevant to everyday life. Or they can be like a mallet: something we get hit over the head with by people who want us to think like them. Research findings can also be like a deity: something we are in awe of and too afraid to question. This book hopes to convey another possibility – that research findings can be like good friends: something that can encourage, advise, stimulate and help us, but also something that we are not afraid to challenge and argue against.

Research

A systematic process of inquiry that leads to the development of new knowledge.

Empirical

Based on concrete experiences or observations, as opposed to purely theoretical conjecture.

So how can research findings be of help? For a start, they can give counsellors and psychotherapists (as well as clients) some very good ideas about where to start from in the absence of other information. Research can only ever tell us about the likelihood of certain things happening, but that knowledge can be enormously valuable if we have virtually nothing else to go on. So, for instance, if a therapist is meeting a depressed client for the first time, it can be very useful to know that, in general, positive outcomes with depressed clients are associated with empathic, caring and warm ways of relating (Castonguay et al., 2006). Subsequently, a therapist may discover that this particular client actually prefers a more distant form of encounter, but until the therapist has a clear sense of what that individual client wants, the research evidence can provide a valuable source of guidance on what the default therapeutic stance should be.

Second, and related to this, research findings can help practitioners to understand therapy from the client’s perspective. Of course, trainee or practising therapists may feel that they already have a good insight into their clients’ experiences – whether through theory, their own experiences in therapy or through listening to, and observing, their own clients – but the evidence indicates that is not always the case (and particularly in the early stages of therapy or when the therapeutic relationship is poor; Timulak, 2008a). For example:

• Therapists’ ratings of the quality of the therapeutic relationship tend to show only moderate agreement with clients’ ratings (e.g. Gurman, 1977; Tryon et al., 2007).
• In just 30 to 40 per cent of instances do therapists agree with clients on what was most significant in therapy sessions; with therapists tending to overestimate the importance of technical, as opposed to relational, aspects (Timulak, 2008a).
• Therapists are often poor at predicting the outcomes of therapy (Kadden et al., 1989), with one study finding that therapists correctly predicted just one out of forty-two clients who ultimately deteriorated (Lambert and Ogles, 1997).
• Client and therapist reports of the same episode of therapy often reveal striking differences in perception. For instance:

Client:	The counseling was worthwhile. It felt good … because it was the first time in years I could talk with someone about what’s on my mind.
Therapist:	We were still in the beginning phases of treatment when she pulled out … I didn’t feel that we were making progress. (Maluccio, 1979: 107–8)

• Counsellors and psychotherapists tend to overestimate their effectiveness relative to other therapists, with one study finding that 90 per cent of therapists put themselves in the top 25 per cent in terms of service delivery (Dew and Reimer, 2003 cited in Worthen and Lambert, 2007).

So although it can be important for trainee and practising therapists to trust their own intuitive sense of what clients are experiencing, it is also important for them to know that they can sometimes get it completely and utterly wrong, and empirical research findings can be a useful way of helping them to understand what their clients might be really going through. For even if their clients are telling them how good the therapeutic work has been or how much they value a particular intervention, the tendency for clients to ‘defer’ to their therapists (Rennie, 1998 see Box 7.2) means that an anonymous, independent examination can sometimes give a more accurate and reliable picture.

In this respect, the value of empirical research findings may not be so much in what they teach therapists, but more the way in which they can challenge therapists to reconsider their implicit assumptions and expectations (Cooper, 2004): shaking them out of rigid belief systems so that they can be more responsive to the actual client in front of them. Here is a personal example: as someone trained in existential psychotherapy (something I’ve defined as ‘similar to person-centred therapy … only more miserable’; Cooper, 2003: 1), my tendency in initial sessions had always been to warn clients of the limits of therapeutic effectiveness. That is not to suggest that I would start off assessment sessions by saying: ‘OK, so your life is meaningless, it has always been meaningless, you have no hope of change … and how can I help you?’ but I did tend to adopt a rather dour stance, emphasising to clients that therapy was not a magic pill and highlighting the challenges that it was likely to involve. Then I came across a research chapter by Snyder and colleagues (1999) which showed, fairly conclusively, that the more clients hoped and believed that their therapy would work the more helpful it tended to be. How did I react? Well, initially I discounted it; but once I’d had a chance to digest it and consider it in the light of some supervisory and client feedback, I came to the conclusion that, perhaps, beginning an episode of therapy with all the things that might not help was possibly not the best starting point for clients. So what do I do now? Well, I don’t tell clients everything is going to be fine the moment that they walk through the door; but I definitely spend less time taking them through all the limitations of the therapeutic enterprise; and if I think that therapy can help a client, I make sure that I tell them that.

Within the world of contemporary healthcare practices, there is another very good reason, albeit a more pragmatic one, why counsellors and psychotherapists should be aware of the research findings: to communicate with others about their work, and to help consumers understand the value of what it is that they do. Today, it is rarely enough to say to a commissioning agency, ‘I really think you should employ me because I know that what I do is helpful.’ And why should it be? Snake-oil salespeople would say exactly the same thing. Funding bodies, whether large-scale corporations or private individuals, are becoming increasingly critical consumers, and want concrete evidence with which to justify their expenditures; so with so much high-quality evidence demonstrating the value that therapy can have (see Chapter 2), it would seem entirely self-defeating for therapists not to have a good working knowledge of this material. As the research itself shows, counsellors and psychotherapists tend to underestimate the strong research support for certain positive therapy findings (Boisvert and Faust, 2006), so knowing what the research really says can help therapists feel more confident in promoting their work.

The Limitations of Research

The premise of this book, then, is that research findings can be like good friends but, as things stand today, it would seem as though many counsellors and psychotherapists are yet to get acquainted: research itself shows that many therapists have little interest in, or familiarity with, empirical research findings in their field (e.g., Boisvert and Faust, 2006). A study of American psychotherapists, for instance, found that only 4 per cent ranked research literature as the most useful source of information on how to practice; with 48 per cent giving top ranking to ‘ongoing experiences with clients’, 10 per cent ranking theoretical literature as the most useful source, and 8 per cent ranking their own experiences as clients most highly (Morrow-Bradley and Elliott, 1986).

No doubt, there are many good reasons why counsellors and psychotherapists should be wary of research findings. For a start, by its very nature, research talks in generalities rather than specifics. So, for instance, the research might show that depressed clients, on average, will exhibit fewer psychiatric symptoms after participating in short-term psychodynamic therapy (Leichsenring, 2001), but this does not mean that the one client in front of a therapist will definitely improve if he or she uses that therapeutic approach. The probability is that he or she will, but on the other hand he or she may not, and it is also possible that he or she will feel a lot worse if the therapist works in that way. In this respect, to base therapeutic practice wholly on empirical research findings – to the exclusion of other factors, such as the expressed preference of the client – would be profoundly unethical. Counselling and psychotherapy research findings can only ever tell us about what is most likely to happen – they cannot give us certainties.

Another limitation of research findings is that they will inevitably be influenced by the researchers’ own assumptions and agendas (see Chapter 3). Take the following example: in a review of studies that compared the effectiveness of different anti-psychotic drugs, Heres and colleagues (2006) found that in 90 per cent of the studies the anti-psychotic drug that came out on top was the one manufactured by the drug company sponsoring the research. Hence, even when research is conducted in a highly rigorous way, biases still manage to creep in. This means that we should always read research findings in a critical way, paying attention to the background and context of whoever conducted the research and what their agendas might be.

Related to this is the fact that research findings are always arrived at through the use of some particular tool, measure or procedure, and these will inevitably influence the kinds of things that are ‘found’. If psychological wellbeing is defined and measured in terms of a lack of ‘mental illness’, for instance, the kinds of therapies that are shown to be most effective may be very different to those if it is defined and measured in terms of a ‘potential for growth’. Researchers can even come up with radically different conclusions with the same set of data if they use different tools of analysis (see, for instance, Elkin et al., 2006; Kim et al., 2006, Chapter 5). It is also important to bear in mind that research is always conducted with a particular sample of people, such that the generalisability of its findings will always be limited (see Chapter 3). We might know, for instance, that non-directive counselling is more effective than usual general practitioner (GP) care for a predominantly white, UK-based sample (King et al., 2000), but does that mean it will also be more effective for clients from black and minority ethnic backgrounds, or for clients in Japan? Again, the point is that research does not give us absolute truths, but one particular perspective on a phenomenon.

Sample

The collection of participants used in a study, from whom we want to make generali...